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Existing Business Lease Application

Please fill out this application. A leasing agent will be in contact with you shortly. Required fields are marked by an asterisk.
*Business Name:
*Contact Name:
*Address:
*City:
*State/Province:
*Zip/Postal Code:
*Country:
*Phone:
Fax:
*E-Mail:
Years in Business:

Description of Your Business
What is your business structure:
Federal ID Number:
Social Security Number:

Banking References
BANK 1
Bank Name:
Account Number:
Bank Phone Number:
BANK 2
Bank Name:
Account Number:
Bank Phone Number:

Trade References
Reference 1
Reference:
Account Number:
Contact:
Phone Number:
Reference 2
Reference:
Account Number:
Contact:
Phone Number:
Reference 3
Reference:
Account Number:
Contact:
Phone Number:

Equipment to be Leased
Lease amount requested:

Equipment Supplier
DirtyBlinds.com
Phone: (716) 685-9574
Fax: (716) 685-9717
1-800-9SONICS (976-6427), USA and Canada ONLY
 
By typing your name in the following space you have certified that you are the person referenced above and that all information provided above is true and correct. Further you grant DirtyBlinds.com and their leasing agent(s) permission to obtain You also certify that you have read and agree with the ECOA Notice below:
Your name:
 
ECOA NOTICE:
Thank you for your business credit application. We will review it carefully and get back to you promptly. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain that statement, please contact us within 60 days from the date that you are notified of our decision. We will send you a written statement of the reasons for the denial within 30 days of your request for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicantís income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers our compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.